Chapter 18 Intraoperative Nursing Management
A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?
Answer + Rationale: The Sims' or lateral position as shown in Option D would be used for renal surgery. The dorsal recumbent position (Option A) is used for most abdominal surgeries, except those for the gallbladder or pelvis. The Trendelenburg position (Option B) is used for surgery on the lower abdomen and pelvis. The lithotomy position (Option C) is used for nearly all perineal, rectal, and vaginal surgical procedures.
A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply. - "The client can be involved in marking the knee, the site for the surgery." - "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." - "The surgeon on the team has never been involved in such a mix-up." - "The client will be involved in the verification process prior to surgery." - "Our surgical team would never make that mistake."
Answer: - "The client can be involved in marking the knee, the site for the surgery." - "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." - "The client will be involved in the verification process prior to surgery."
When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include? A.) "You shouldn't experience a headache after this type of anesthesia." B.) "Normally, the blood pressure drops fairly low initially." C.) "The anesthetic is introduced directly into the spinal cord." D.) "You won't be able to move, but you'll be able to feel sensations."
Answer: A.) "You shouldn't experience a headache after this type of anesthesia." Rationale: With epidural anesthesia, a headache usually does not occur. If the dura mater is punctured during epidural anesthesia and the anesthetic travels toward the head, high spinal anesthesia can occur, producing severe hypotension and respiratory depression and arrest. This is a complication and not a typical reaction. The anesthetic is introduced into the epidural space surrounding the dura mater of the spinal cord. It blocks sensory, motor, and autonomic functions.
The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system? A.) Cardiovascular system B.) Endocrine system C.) Gastrointestinal system D.) Genitourinary system
Answer: A.) Cardiovascular system Rationale: Depolarizing muscle relaxants can cause cardiac dysrhythmias.
A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? A.) Circulating nurse B.) Scrub nurse C.) Surgeon D.) Registered nurse first assistant
Answer: A.) Circulating nurse
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? A.) Dantrolene sodium B.) Fentanyl citrate C.) Naloxone D.) Thiopental sodium
Answer: A.) Dantrolene sodium
Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? A.) Halothane B.) Fentanyl C.) Succinylcholine D.) Propofol
Answer: A.) Halothane Rationale: Halothane is an example of an inhalation anesthetic. Fentanyl, succinylcholine, and propofol are commonly used intravenous agents for anesthesia.
Which position is used for perineal surgical procedures? A.) Lithotomy B.) Trendelenburg C.) Sims D.) Dorsal recumbent
Answer: A.) Lithotomy Rationale: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgeries. The Trendelenburg position is usually used for surgery on the lower abdomen and pelvis. The Sims or lateral position is used for renal surgery. The dorsal recumbent position is the usual position for surgical procedures.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? A.) Report the infection to an immediate supervisor. B.) Ensure the infection is covered with a dressing. C.) Return to work after taking antibiotics for 24 hours. D.) Request a role change to circulating nurse.
Answer: A.) Report the infection to an immediate supervisor.
There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. A.) Stage I: beginning anesthesia B.) Stage II: excitement C.) Stage III: surgical anesthesia D.) Stage IV: medullary depression
Answer: B.) Stage II: excitement
The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure? A.) Risk for perioperative positioning injury related to positioning in the OR B.) Risk of latex allergy response related to possible exposure in the OR environment C.) Disturbed sensory perception related to the effects of general anesthesia D.) Anxiety related to ineffective coping with surgical concerns
Answer: A.) Risk for perioperative positioning injury related to positioning in the OR
Which clinical manifestation is often the earliest sign of malignant hyperthermia? A.) Tachycardia (heart rate >150 beats per minute) B.) Hypotension C.) Elevated temperature D.) Oliguria
Answer: A.) Tachycardia (heart rate >150 beats per minute)
A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? A.) Verify consent. B.) Document the start of surgery. C.) Acquire ordered blood products. D.) Count sponges and syringes.
Answer: A.) Verify consent.
The nurse recognizes that the older adult is at risk for surgical complications due to: A.) decreased renal function B.) increased cardiac output C.) increased skeletal mass D.) decreased adipose tissue
Answer: A.) decreased renal function Rationale: Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.
The nurse recognizes the client has reached stage III of general anesthesia when the client: A.) lies quietly on the table B.) displays agitation due to noise C.) shouts, talks, or sings D.) exhibits shallow respirations and a weak, thready pulse
Answer: A.) lies quietly on the table Rationale: Understanding the stages of anesthesia is necessary for nurses because of the emotional support that the client may need. Stage III or surgical anesthesia is reached when the patient is unconscious and lies quietly on the table. The pupils are small but constrict when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. Clients in stage I of anesthesia may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. These sensations can result in agitation. Stage II of anesthesia is characterized variously by struggling, shouting, talking, singing, laughing, or crying, and is often avoided if IV anesthetic agents are given smoothly and quickly. Stage IV is reached if too much anesthesia is given. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued immediately and respiratory and circulatory support is initiated to prevent death.
A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia? A.) oxygen B.) alfentanil C.) rocuronium D.) lidocaine
Answer: A.) oxygen Rationale: Sevoflurane is an inhalation anesthetic always combined with oxygen to decrease the risk of coughing and laryngospasm. It would not be combined with alfentanil, rocuronium, or lidocaine. Alfentanil and rocuronium are intravenous anesthetics. Lidocaine is a local anesthetic.
A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse? A.) "The kidneys will eliminate the inhalant with urination." B.) "The lungs primarily eliminate the anesthesia." C.) "The skin will eliminate the anesthesia through evaporation." D.) "The liver will eliminate the inhalant anesthesia."
Answer: B.) "The lungs primarily eliminate the anesthesia."
A new scrub technician is being oriented to the operating room. The scrub technician states to the nurse, "You can skip the fire safety information because I have worked in hospitals for the past 10 years." What is the best response by the nurse? A.) "I know this information is not exciting but I'm required to cover it with you." B.) "The operating room has some unique circumstances that increases the chances of fire." C.) "OK, but you will be required to review the hospital's policy on fire safety on your own." D.) "This is a requirement of your job; just tough through it."
Answer: B.) "The operating room has some unique circumstances that increases the chances of fire."
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: A.) Anesthesiologist B.) Circulating nurse C.) Scrub nurse D.) Surgeon
Answer: B.) Circulating nurse
The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? A.) Unresponsive to verbal or tactile stimuli B.) Denies sensation to perineum and lower abdomen C.) Yelling and pulling at equipment D.) No movement in right lower leg
Answer: B.) Denies sensation to perineum and lower abdomen
A patient is to receive general anesthesia. The nurse anticipates that which of the following would be used for induction? A.) Isoflurane B.) Etomidate C.) Nitrous oxide D.) Tetracaine
Answer: B.) Etomidate
Which stage of surgical anesthesia is also known as excitement? A.) I B.) II C.) III D.) IV
Answer: B.) II
A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? A.) I B.) II C.) III D.) IV
Answer: B.) II Rationale: Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia characterized by unconsciousness and quietness. Surgical anesthesia is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.
How would the operating room nurse place a patient in the Trendelenburg position? A.) Flat on his back with his arms next to his sides B.) On his back with his head lowered so that the plane of his body meets the horizontal on an angle C.) On his back with his legs and thighs flexed at right angles D.) On his side with his uppermost leg adducted and flexed at the knee
Answer: B.) On his back with his head lowered so that the plane of his body meets the horizontal on an angle
The client vomits during the surgical procedure. The best action by the nurse is: A.) Increase the IV infusion rate to compensate for lost fluids. B.) Suction the client to remove saliva and gastric secretions. C.) Lower the head of the operating table to promote circulation to the brain. D.) Administer an anti-emetic to alleviate nausea.
Answer: B.) Suction the client to remove saliva and gastric secretions.
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? A.) Circulating nurse B.) Surgeon C.) Scrub nurse D.) Anesthetist
Answer: B.) Surgeon
In which zone of the surgical area are street clothes allowed? A.) Restricted B.) Unrestricted C.) Semi-restricted D.) Limited
Answer: B.) Unrestricted
A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate? A.) "You will be placed flat on the table, face down." B.) "You will be on your back with the head of the bed at 30 degrees." C.) "You will be lying on your side with your knees to your chest." D.) "You will be flat on your back with the table slanted so your head is below your feet."
Answer: C.) "You will be lying on your side with your knees to your chest." Rationale: For the lumbar puncture procedure, the client usually lies on the side in a knees-to-chest position. A position flat on the table, face down does not open the vertebral spaces to allow access for the lumbar puncture. Having the client lie on their back does not allow access to the surgical site.
The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate? A.) Monitor for faulty electrical equipment. B.) Alert personnel who break sterile technique. C.) Allow unnecessary personnel to enter the OR environment. D.) Maintain the positive pressure OR environment.
Answer: C.) Allow unnecessary personnel to enter the OR environment.
A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following? A.) Increased anxiety level B.) Increased tissue elasticity C.) Decreased lean tissue mass D.) Impaired thermoregulation
Answer: C.) Decreased lean tissue mass
The nurse positions the client in the lithotomy position in preparation for A.) Renal surgery B.) Pelvic surgery C.) Perineal surgery D.) Abdominal surgery
Answer: C.) Perineal surgery
The surgical client is at risk for injury related to positioning. Which of the following clinical manifestations exhibited by the client would indicate the goal was met of avoiding injury? A.) Absence of itching B.) Pulse oximetry 98% C.) Peripheral pulses palpable D.) Vital signs within normal limits for client
Answer: C.) Peripheral pulses palpable Rationale: Surgical clients are at risk for pressure ulcers and damage to nerves and blood vessels as a result of awkward positioning required for surgical procedures. Palpable peripheral pulses indicate integrity of the blood vessels.
The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse? A.) Remove the item from the sterile field. B.) Mark the client's chart for future review of infections. C.) Remove the entire sterile field from use. D.) Ask another nurse to review the technique used.
Answer: C.) Remove the entire sterile field from use.
Which of the following techniques least exhibits surgical asepsis? A.) Adding only sterile items to a sterile field B.) Keeping sterile gloved hands above the waist C.) Suctioning the nasopharyngeal cavity of a client D.) Placing the sterile field at least one foot away from personnel
Answer: C.) Suctioning the nasopharyngeal cavity of a client
A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? A.) Malignant hyperthermia occurs in the operating room only. B.) A client can develop malignant hyperthermia only with intravenous anesthesia after surgery. C.) The client can develop malignant hyperthermia up to 24 hours after surgery. D.) The client will need to be discharged with special instructions.
Answer: C.) The client can develop malignant hyperthermia up to 24 hours after surgery.
Which of the following is an inappropriate nursing action by the surgical nurse? A.) Covering the hair with a surgical cap B.) Wearing a surgical jacket with knitted cuffs on the sleeves C.) Wearing sterile gloves over artificial nails D.) Changing shoe covers that become torn
Answer: C.) Wearing sterile gloves over artificial nails
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? A.) hypothermia B.) infection C.) malignant hyperthermia D.) fluid volume excess
Answer: C.) malignant hyperthermia
What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block? A.) "Avoid drinking liquids until the gag reflex returns." B.) "Avoid eating milk products for 24 hours." C.) "Notify a nurse if you experience blood in your urine." D.) "Remain supine for the time specified by the physician."
Answer: D.) "Remain supine for the time specified by the physician." Rationale: The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.
A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate? A.) Temporarily set the OR temperature to 30°C. B.) Place warm damp drapes on the client, replacing them every 5 minutes. C.) Administer IV fluids warmed to room temperature. D.) Apply a warm air blanket, gradually increasing body temperature.
Answer: D.) Apply a warm air blanket, gradually increasing body temperature.
The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching? A.) Sore throat B.) Itching C.) Seizures D.) Headache
Answer: D.) Headache Rationale: Headache is a common effect following spinal anesthesia.
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? A.) Hair is pulled back and covered by a cap. B.) Scrub top and drawstring are tucked into pants. C.) Shoe covers are used. D.) Mask is placed over nose and extends to bottom lip.
Answer: D.) Mask is placed over nose and extends to bottom lip.
The scrub nurse is responsible for: A.) Calling the "time-out" to verify the surgical site and procedure B.) Monitoring the administration of the anesthesia C.) Monitoring the operating-room personnel for breaks in sterile technique D.) Preparing the sterile instruments for the surgical procedure
Answer: D.) Preparing the sterile instruments for the surgical procedure
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants? A.) Circulating nurse B.) First assistant C.) Certified registered nurse anesthetist D.) Scrub nurse
Answer: D.) Scrub nurse
The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? A.) Stage I B.) Stage II C.) Stage III D.) Stage IV
Answer: D.) Stage IV Rationale: Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? A.) Pulse rate of 110 beats/min B.) Respiratory rate of 18 breaths/min C.) Blood pressure of 104/62 mm Hg D.) Temperature of 102.5°F (39°C)
Answer: D.) Temperature of 102.5°F (39°C) Rationale: Intra operative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
Which of the following medications would the nurse expect to be used to facilitate intubation of the client? A.) diazepam (Valium) B.) pancuronium (Pavulon) C.) fentanyl (Sublimaze) D.) atracurium (Tracrium)
Answer: D.) atracurium (Tracrium)